S.L. 585.1 Art. 70Procedures.

Undertaking’s radiation protection programmes shall include that:

(a) written protocols for every type of standard medical radiological procedure are established for each equipment for relevant categories of patients;

(b) information relating to patient exposure forms part of the report of the medical radiological procedure;

(c) referral guidelines for medical imaging, taking into account the radiation doses, are available to the referrers;

(d) clinical audits are carried out in accordance to the national procedures established by the Commission;

(e) appropriate reviews are undertaken whenever diagnostic reference levels are consistently exceeded and that appropriate corrective action is taken without undue delay;

(f) procedures are in place for:

(i) the correct identification of individuals to be exposed to ionising radiation;

(ii) making enquiries of females of childbearing age to establish whether the individual is or may be pregnant or breastfeeding;

(iii) approval of individuals to act as referrers, practitioners, and persons performing the practical aspects;

(iv) quality assurance; administered activity;

(vi) medical and biomedical research programmes including the use of dose constraints;

(vii) giving of information and written instructions as referred to in regulation 66(7);

(viii) recording of doses for each medical exposure including, where appropriate, factors relevant to patient dose;

(ix) ensuring that the probability and magnitude of accidental or unintended doses to patients from radiological practices are reduced as far as reasonably achievable;

(x) responding and reporting of incidents and accidents;

(xi) record keeping;

(xii) arrangements for monitoring workers and the workplace;

(xiii) education and training programme on the nature of the hazards, protection and safety;

(xiv) methods for periodically reviewing and auditing the performance of the radiation protection programme;

(xv) any others as required to be able to demonstrate compliance with these regulations.